CQC report explained · a residential care home
What the CQC found at Bowens Field
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
- Safe?
- Requires improvement
- Inspectors found insufficient staffing, weak infection control and poor risk management. Medicines were administered and recorded safely, but the overall safety rating deteriorated from Good.
- Effective?
- Requires improvement
- Care plans were personalised and people had access to food and healthcare, but staff did not always receive regular ongoing training. This rating deteriorated from Good.
- Caring?
- Requires improvement
- Staff were observed treating people with kindness, respecting privacy and supporting choices. However, staffing shortages and safety concerns affected the quality of care, so the rating remained Requires Improvement.
- Responsive?
- Requires improvement
- People had personalised care plans and were supported with activities and relationships. However, information about end-of-life wishes and complaints was not available in forms people could understand. This rating deteriorated from Good.
- Well-led?
- Requires improvement
- Leaders understood people's needs and had plans for improvement, but governance and quality monitoring did not identify or prevent several safety and training problems. This rating deteriorated from Good.
What inspectors found, June 2022
Rated Requires Improvement; inspectors found kind and personalised care, but staffing, infection control and management checks put people at risk.
The inspection was unannounced and took place on 3 March 2022. One inspector spoke with two people and two staff members, observed care, and reviewed care records, medicines records, risk assessments and training records. Further discussions took place after the visit.
The home supported three people with learning disabilities or autism. Inspectors found staff were kind, respected privacy and supported people to make choices. Care plans were detailed and personalised. People were supported with medicines, food, healthcare and activities.
There were important safety concerns. Staffing levels did not always provide the one-to-one support people had been assessed and funded for. Infection control was not robust. Risk checks, fire drill records, staff training records and wider quality monitoring were also not effective.
The overall rating and all five key question ratings were Requires Improvement. Safe, effective, responsive and well-led all deteriorated from Good at the previous inspection, while Caring remained Requires Improvement. The provider was told to send a report explaining what action it would take.
Personalised care
Care plans reflected people's individual needs, wishes and aspirations. People were involved in planning their support where possible.
“People had care and support plans that were personalised, holistic, strengths-based and reflected their needs and aspirations, included physical and mental health needs.” from the report
Kind and respectful staff
Staff were observed encouraging people, respecting their choices and giving them privacy. They understood how people communicated, including through facial expressions and body language.
“We observed people were treated with kindness and a staff member encouraging them whilst undertaking tasks and praising them at the same time.” from the report
Support with medicines
Staff had medicines training and competency checks. Records showed people received their medicines as prescribed.
“People were supported by staff who followed systems and processes to administer, record and store medicines safely.” from the report
Food and healthcare
People chose food, helped prepare meals and received support to eat and drink enough. Staff helped people access healthcare services when needed.
“People were involved in choosing their food, shopping, and planning their meals.” from the report
Not enough staff
seriousStaffing levels were not enough to provide the one-to-one support people had been assessed and funded for. This may have limited people's support with activities and daily needs.
“There were insufficient staff to meet people's needs.” from the report
Weak infection control
seriousInspectors were not assured that visitors were protected from spreading infections. Handwashing, COVID-19 checks and access to the PPE bin were not handled properly.
“The provider did not use effective infection, prevention and control measures to keep people safe.” from the report
Risk and fire checks
seriousChemicals were accessible in an office until inspectors pointed this out. Fire drill training had expired for three of five staff members, and monitoring had not ensured regular drills.
“People were placed at risk of potential harm because of poor risk management.” from the report
Poor management monitoring
seriousQuality checks did not identify or resolve problems with staffing, infection control, fire drills and ongoing training. This meant leaders did not have reliable oversight of safety.
“Governance processes were ineffective and did not always help to hold staff to account or to keep people safe.” from the report
Information people could understand
needs fixingPeople did not have accessible information about making complaints. The home also had not recorded people's wishes about end-of-life care, although no one was receiving such care during the inspection.
“People did not have access to information in a format they could understand about how to make a complaint.” from the report
- 01How are you now ensuring each person receives the one-to-one support they have been assessed and funded for?
- 02What changes have been made to infection control, including visitor checks, handwashing and safe disposal of PPE?
- 03How often are fire drills now completed, and are all staff up to date with fire safety training?
- 04How do you check that staff receive all required ongoing training and that records are accurate?
- 05How can people living here make a complaint or discuss end-of-life wishes in a way they can understand?
This was an unannounced inspection covering all five key questions and infection prevention and control; the previous inspection was rated Good overall in 2018, with Caring rated Requires Improvement. This explanation was written from the published report of 14 June 2022 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, November 2018
Rated Good; inspectors found safe, kind and personalised care, with end of life wishes still to be explored.
The home supports three adults with learning disabilities. Inspectors visited without notice on 11 and 15 October 2018. They spoke with people living there, an advocate, staff and the manager, and reviewed care files, staff files, medicines records, complaints and other records.
The home was rated Good overall and Good in all five areas: Safe, Effective, Caring, Responsive and Well-led. Inspectors found enough staff, safe medicine procedures, suitable care plans, kind support and activities that matched people's interests.
The home had systems to monitor quality, and staff said they felt supported. The rating stayed Good because inspectors found no evidence or information showing risks or concerns since the previous inspection.
Inspectors noted that people sometimes had to compromise because one staff member supported three people. They also noted that the provider had not yet explored people's wishes about end of life care.
Safe medicines support
Medicines were given on time by trained staff. Records and instructions were clear, including for medicines needed only when required.
“People received their medicine on time, by trained staff.” from the report
Personalised care
Care plans included communication profiles, personal history, routines, health plans and individual goals. Staff used different communication methods to involve people.
“People had care plans that contained detailed information about their needs and choices.” from the report
Kind and respectful staff
Inspectors saw staff treating people politely and compassionately. Staff respected privacy and encouraged people to be independent.
“People were treated with kindness and respect by staff.” from the report
Activities and community life
People took part in activities they enjoyed, both at home and in the local community. The manager had secured more one-to-one funding for individual activities.
“People were engaged in activities in the community and on the day of inspection were in and out of the home.” from the report
Quality monitoring
The manager completed regular audits and action plans. Records showed that tasks, including maintenance, were followed up.
“The Registered manager completed a quality audit each quarter and produced an action plan.” from the report
End of life wishes not yet explored
minorThe provider had not yet discussed end of life care wishes with people or their families. The manager said this would be explored in the future.
“Due to people living at Bowens Field being of working age and in good health the provider has not yet explored end of life care with people or their families.” from the report
Occasional limits on shared staffing
needs fixingPeople sometimes had to compromise because one staff member supported three people. The provider had increased one-to-one funding and inspectors saw this being used for individual activities.
“People did have to compromise throughout the week as sometimes there was only one staff member to support three people.” from the report
- 01How will you make sure each person gets enough individual time when one staff member is supporting three people?
- 02How are the increased one-to-one hours being used for each person?
- 03When will you discuss end of life wishes with the people living here and their families?
- 04How do you use people's communication profiles and pictures to involve them in care planning and daily choices?
- 05How do you check that medicines, including as-required medicines, are given as intended?
This was an unannounced inspection of the overall service covering all five CQC questions; the report says the inspection used a shorter format because the overall rating had not changed. This explanation was written from the published report of 24 November 2018 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Bowens Field
3 rated inspections over 7 years: the service has slipped, from Good to Requires improvement.
- June 2022Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Requires improvement
- November 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- October 2015GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- July 2014
Registered with the Care Quality Commission on 1 July 2014.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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